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Based on policy review, medical record review, staff interview, observations and review of the facility's training materials, the facility failed to ensure ongoing assessment of patient needs and failed to follow physician orders (A392). The facility failed to ensure infection control policies were followed for nursing services (A395). The facility failed to administer a STAT medication in accordance with physician orders and in accordance with the facility's policy, failed to ensure oxygen was administered in accordance with physician orders and failed to ensure orders for oxygen contained the amount to be administered (A405). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients received safe care in accordance with physician orders and in accordance with the facility's policies. This had the potential to affect all of the facility's 243 active patients.

Based on medical record review, staff interview and facility training materials and policy review, the facility failed to ensure ongoing assessment of patient needs and following physician orders for three of ten patients reviewed. (Patient #1, Patient #4 and Patient #10) The facility census was 243 patients.

Findings include:

1. Review of the medical record for Patient #1 revealed an admission date of 08/06/16 and diagnoses to include COPD and shortness of breath. A physician order dated 08/06/16 revealed maintain oxygen saturation levels greater than 88 % and notify physician for oxygen saturations less than 88 %.

Review of an occupational therapy note dated 08/09/16 at 11:24 AM revealed the patient's pulse oximeter reading was 86 % and dropped to 83 % with activity. The record failed to reveal documentation that the nurse or physician was notified of the low oxygen level. The next pulse oximeter reading was recorded as 86% by a patient care technician at 12:10 PM. The record failed to include notification to the nurse or physician of the low oxygen level. The record failed to include intervention to increase the patient's oxygen level to the physician prescribed level. The patient's next pulse oximeter reading was at 4:00 PM by a patient care technician and was 88%. The record failed to include notification to the nurse.

An interview with Staff C on 08/10/16 at 10:15 PM confirmed the above findings.

Review of the facility competency based assessments revealed the patient care technicians should report to the nurse pulse oximeter readings less than 90%.

2. Review of the medical record for Patient #4 revealed an admission date of 08/06/16 and diagnoses to include metabolic acidosis and shortness of breath. A physician order dated 08/06/16 included cardiac monitoring and maintain oxygen saturation levels greater than 90 %.

Review of the nursing progress notes dated 08/07/16 at 11:03 AM revealed the nurse was notified the patient had a cardiac alarm of heart rate in the 140's and the nurse acknowledged the report. A nursing progress note of the same date at 11:06 AM revealed the nurse was notified the patient had an increased heart rate alarm and the nurse reported to only call if the rate was sustained. The record failed to include a documented assessment of the patient in response to the two telemetry alarms of increased heart rate.

On 08/08/16 at 6:00 AM the patient was noted with pulse oximeter reading of 91% and oxygen per nasal cannula at 4 liters. The next pulse oximeter reading was noted at 2:00 PM where the patient care technician recorded a pulse oximeter level of 90 % but the patient was noted as on 15 liters of oxygen per ventimask. The record failed to include nursing or respiratory progress notes or documentation to indicate the change in oxygen level and modality.

Review of a written statement from a nurse manager interview on 08/10/16 with the patient care technician that cared for the patient on 08/07/16 revealed at 7:00 AM the patient had a pulse oximeter reading of 73%. The technician notified the charge nurse, who determined the patient was hypoxic (low oxygen levels) and tachypneic (increased heart rate). The patient was emergently placed on a 50% venturi mask and the respiratory therapist notified. At 8:00 AM the respiratory therapist administered a breathing treatment and titrated the oxygen for the safety of the patient. Review of the record failed to reveal documentation of the hypoxic event, interventions or additional follow up to the event.

Review of a pulse oximeter reading on 08/08/16 at 3:00 PM revealed a reading of 88%. The record failed to include interventions to meet the physician prescribed oxygen saturation level. The next pulse oximeter reading was not recorded until 10:00 PM.

Review of a pulse oximeter reading on 08/09/16 at 2:00 PM revealed readings of 89% per the patient care technician and confirmed by the nurse. The record failed to include intervention to meet the physician prescribed oxygen saturation level.

An interview with Staff C on 08/10/16 at 10:07 AM confirmed the above findings.

Review of the facility Patient Clinical Alarms Policy revealed Registered Nurses are responsible for responding to telemetry alarms immediately by assessing the patient and following the chain of command notification process when patient monitoring issues occur.

3. Review of the medical record for Patient #10 revealed admission to ICU after surgery for an Ivor-Lewis esophagectomy (removal of portion of esophagus). Per discharge summary approximately 10 days post operatively Patient #10 developed a severe pneumonia and sepsis, never recovered and became progressively worse from his sepsis from pneumonia, presumably due to aspiration as well. Review of the consultation note dated 06/15/16 at 4:37 PM revealed the patient's breath sounds were coarse bilaterally with a right sided chest tube post operatively.

Review of the medical record for Patient #10 revealed an order was written, on 06/15/16 at 3:48 PM, for Patient #10 to perform incentive spirometry every one hour while awake, 10 times per hour.

Review of a physician's progress note dated 06/16/16 revealed the patient's pulmonary assessment documented a weak inspiratory effort.

The medical record contained documentation of Patient #10 performing incentive spirometry (a device to improve inspiratory volume) on 06/18/16 at 12:00 AM, 5:03 AM and 8:00 PM. The medical record contained documentation of Patient #10 being awake at 5:00 AM on 06/18/16 and being awake on 06/18/16 at 10:00 PM. The medical record contained documentation of Patient #10 being awake on 06/18/16 at 8:00 AM, 10:00 AM and 12:00 PM. The medical record revealed Patient #10 was sleeping on 06/18/16 at 2:00 PM. The medical record did not contain evidence of Patient #10 performing the incentive spirometry as ordered by the physician.

Review of the record revealed a physician order for Patient #10's weight to be measured daily on 06/17/16 at 10:20 AM. The order was discontinued on 06/24/16 at 12:09 PM. The medical record did not contain Patient #10's weight on 06/17/16 and 06/21/16.

Further review of the medical record revealed an order to notify the physician of a heart rate above 120 on 06/15/16 at 3:47 PM. On 06/17/16 at 1:04 PM, a nurse documented Patient #10's heart rate as 131. The medical record did not contain evidence the physician was notified of the reading.

The findings were shared with Staff H on 08/09/16 at approximately 2:25 PM and confirmed.

Based on observation, medical record review, staff interview and policy review the facility failed to ensure infection control policies were followed for nursing services for two (Patient #6, Patient #4) of three observations of nursing services. The facility census was 243 patients.

Findings include:

1. An observation of wound care on 08/10/16 at 8:00 AM revealed Patient #6 on contact isolation. During the wound treatment the staff required a flashlight to visualize the wound and Staff B reached into his/her pants pocket to get a cell phone to access a flash light while wearing gloves that had touched the patient's leg. When another staff member had a pen light, Staff B replaced the cell phone to his/her pocket without cleaning or decontaminating the phone. After completing wound care, Staff A used a marker to date and initial the wound vac dressing without changing gloves. Staff A then placed the marker into his/her uniform pocket without decontaminating the marker.

An interview with Staff A at 8:20 AM confirmed the marker was placed in a pocket without cleaning or disinfection.

An interview with Staff G at 8:25 AM confirmed the above breaches in infection control policy.

Review of the medical record for Patient #6 revealed an admission date of 08/04/16 and diagnoses to include Achilles tendon infection, osteomyelitis, and multi-drug resistant infection. Review of the physician order dated 08/0416 revealed the patient was on contact isolation.

Review of the facility Infection Control Isolation Guidelines Policy revealed gloves should be changed after contact with potentially infective material or objects that could be contaminated. Dedicate equipment to that patient or clean and disinfect it before using on another patient.

2. An observation of medication administration on 08/10/16 for Patient #4 revealed Staff E setting up medication for the patient. At 9:05 AM the staff member's hospital cell phone rang, Staff E answered the phone, took notes and set down the phone. Staff E proceeded to tear open the unit dose packages of eight prescribed medications and picked up each pill with his/her fingers to place them in the medication cup for the patient. Staff E failed to wash his/her hands or use hand sanitizer after touching the cell phone and prior to touching the patient's medications.

An interview with Staff E at 9:15 AM confirmed the above finding.

Review of the facility Infection Control Hand Hygiene Policy revealed personnel should wash hands or use hand sanitizer after contact with environmental surfaces that may be contaminated.

Based on medical record review, staff interview and policy review, the facility failed to administer a STAT medication in accordance with physician orders and in accordance with the facility's policy for one (Patient #10) of ten medical records reviewed. The facility failed to ensure oxygen was administered in accordance with physician orders and failed to ensure orders for oxygen contained the amount to be administered for one (Patient #10) of ten medical records reviewed. The facility's active census at the time of the survey was 243 patients.
Findings include:
The medical record review for Patient #10 revealed an order for Zosyn every eight hours STAT (immediately) for Sepsis on 06/26/16 at 2:39 PM.

The medical record contained a RN Communication to Pharmacy (Medication -Replace) note on 6/26/2016 5:14 PM requesting the pharmacy to send the Zosyn for Patient #10 as soon as possible.

The medical record contained documentation of Zosyn being administered to Patient #10 on 06/26/16 at 5:39 PM and on 06/27/16 at 2:14 AM.

The facility's Medication Orders policy was reviewed. The policy stated order priority for STAT medications is to be given within 30 minutes. The policy stated STAT medication designation is reserved for highest priority orders (Life threatening situations). Although STAT orders have a maximum turnaround time of 30 minutes, in many cases they need to be fulfilled immediately or within a few minutes depending on the situation. When a prescriber's order for a medications is "STAT", it shall be processed immediately.

The facility's Medication Administration and Self-Administration Guidelines policy was reviewed. The policy stated STAT doses are immediate.

Further review of the record for Patient #10 revealed orders for oxygen. The first order for oxygen located in the medical record was written on 6/26/2016 11:47 AM. The oxygen order did not contain the method to administer the oxygen or the Liter flow to administer. The medical record did not contain an order for oxygen prior to 06/26/16.

The medical record revealed Patient #10 received and had oxygen rate changes as follows:

On 06/15/16 the oxygen was documented at 4:00 PM as 8 L/min, at 9:00 PM 6 L/min and at 9:30 PM as 4 L/min.

On 06/16/16 the oxygen was documented at 1:30 AM as 2 L/min, at 2:00 AM 1 L/min, at 3:47 AM 4 L/min and at 6:59 AM 2 L/min.

On 06/17/16 the oxygen was documented at 11:15 PM as 3 L/min.

On 06/18/16 the oxygen was documented at 4:00 AM 2 L/min and at 8:00 PM 3 L/min.
06/19/16 8:30 pm 3 L/min, 06/20/16 4:51 PM 3 L/min, 06/21/16 9:01 AM 3 L/min, 06/22/16 8:00 PM 3 L/min, 06/23/16 7:00 AM 3 L/min, 06/24/16 11:00 PM 3 L/min, 06/25/16 11:00 AM 3 L/min and 06/26/16 at 10:00 AM at 4L/min.

The facility's Medication Orders policy was reviewed. The policy stated medication orders must have the dose of the medication and the route of the administration on the Medication Administration Record.

On 08/09/16 at 2:43 PM, the findings were shared with Staff H and confirmed.